Hypertonic
Saline Appears to Be An Effective Alternative to Mannitol in the Treatment
of Elevated Intracranial Pressure

Question

Is
hypertonic saline a more effective therapeutic measure to reduce intracranial
pressure in children with intracranial masses compared to Mannitol?

Clinical
Bottom Lines

Although Mannitol remains the most commonly used agent for reducing
ICP in the acute setting for intracranial masses, after reviewing "expert
opinion" level evidence both in the literature and with our PICU
attendings, it appears that hypertonic saline may be preferable based
on a comparison of the adverse effect profile (less predisposition towards
hemodynamic instability, less risk of renal complications, easier to
track and follow with serum sodium levels).

Additionally, it appears that in the acute setting, using boluses of
both hypertonic saline and mannitol (as was performed in the clinical
scenario that stirred this investigation) are based on anecdotal evidence.

Summary of Key Evidence

Ethics:
IRB approved; no informed consent needed

Setting:
Egleston Children's Hospital (Emory University) PICU

Inclusion
Criteria: Admission to PICU, Invasive intracranial monitor, Required
at least one dose of HS or mannitol for increased ICP

Study
Results: Study 1: Hypertonic Saline Infusions only compared to Mannitol
Infusions only
-statistically significant difference in median GCS between group receiving
HS and those receiving mannitol, higher GCS scores in HS group (p <0.02)
-statistically significant difference in baseline ICP of mannitol group
compared to HS group, higher ICP scores in Mannitol group (p<0.02)
-significant reductions in ICP were noted at 30 , 60 and 120 minutes
following the HS infusions
-CPP increased significantly at 60 and 120 minutes after HS infusions
-No significant change in HR or MAP
-Significant reductions in ICP were seen at 60 and 120 minutes after
mannitol infusions
-No significant changes were noted in CPP, HR, or MAPStudy 2: Hypertonic Saline and Mannitol Infusions both received;
compared within individuals at time of administration
-Statistically significant difference between baseline ICP prior to
receiving Mannitol compared to ICP prior to receiving HS (p<0.05)
-Significant reductions in ICP at 60 and 120 minutes for infusions of
Mannitol
-Significant reductions in ICP at 60 and 120 minutes for infusions of
HS
-Significant reductions in CPP at 30, 60 and 120 minutes for infusions
of HS compared to Mannitol

Additional
Comments

Key flaw in the study was the baseline ICP in both studies, in both
groups being analyzed, were different at baseline and found to be statistically
significant; ICP was actual outcome that was being evaluated in this
study; furthermore the GCS scores at baseline were also different at
baseline and considered statistically significant. Thus the question
posed by study could not be answered as it would not be a valid comparison;
the outcomes of Mannitol could not be compared to HS and be considered
valid.

Two different dosages of Mannitol were used; they were of different
osmolalities and one dose was not comparable to the osmolality of HS
used; the dose that was used was not identified.

Method of Analysis chosen for the study does not appear optimal; Kruskal
Wallis often used for three or more treatment groups consisting of different
individuals; a more appropriate method of statistical analysis would
have be the Two Factor Repeated Measures Analysis of Variance (evaluates
multiple treatments in the same individual with an acknowledgment of
a baseline).